Washington, D.C. Trip 2012
Medication/Health Concerns Form
Section A. If your child has a prescription medication that needs to be given during the trip, Section A
needs to be signed by both physician and parent/guardian.
*Prescription medication must be in the original container, clearly labeled with the student’s name, name of medication and dosage. If you need an extra labeled container, your pharmacist can provide you with one. Do not send medication in a baggie or envelope. *If your child has an Epi Pen or an inhaler, please check appropriate box. We will use forms already at school if we have them. If we do not have forms at school, we will need those filled out. Section B. Relates to non prescription medication which was signed in Oct. 2011. Fill out only if any
changes are needed.
Section C. This section should be signed if you would like the nurse to administer a non prescription
medication that is not listed in B. This medication must be provided in the original container, clearly
labeled with the student’s name.
Section D. Please indicate here if you would like the nurse to call you.
The attached form and any medications need to be in clinic by Monday, May 21, 2012
Please do not send medication as your child is getting on the bus. We will keep all medications with us in a central location. The exception to this would be medication such as inhalers or epi pens that students need to carry or to be given to the chaperone to carry. Please call if you have questions or last minute medication changes or additions. Joann Spain R.N. Office: 237-4309 ext 3146. Home: 846-1572 Chris Cleary R.N. Office: 338-2098 ext 473. Home: 237-5912 WASHINGTON DC HEALTH/MEDICATION FORM
Student:_____________________________________ ___________________________is under my care and should have: (student’s name) (medication) (dosage) (am, pm, as needed, other) Reason for giving med (ie: diagnosis, health concern):_________________________________ Possible side effects:___________________________________________________________ Special administration or storage instructions: ______________________________________ Physicians signature:__________________________________________date:_____________ Parents’ signature:___________________________________________ date:_____________ Epi Pen: Self carry_____ Chaperone carry _____ Both _____ Authorization form obtained____ Inhaler: Type________ Self carry__ Chaperone carry__ Both__Authorization form obtained____ B. Non Prescription Medication: No need to sign again if filled out in Oct. 2011. Use if any changes needed. I GIVE PERMISSION for the following medications to be administered AS NEEDED if requested by student and judged helpful by school personnel: acetaminophen, ibuprofen, over the counter decongestant, Claritin, Robitussin, Pepto Bismol, simethicone gas relief, Imodium, Benadryl, Dramamine and cough drops. Parent/Guardian signature:_____________________________date:____________________ I DO NOT GIVE PERMISSION for my child to take the above medication. Parent/Guardian signature:____________________________date:_____________________ ____________________________________________________________________________ C. This section should be signed if you would like a non prescription medication not listed above in (name of medication) (dosage) (reason) (when) _____________________________________________________________________________________ D. I would like nurse contact before the trip about health concerns. Yes_____ No_____ Name_____________________________ Phone number___________________________ This form and any medications need to be in the clinic by Monday, May 21, 2012


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